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The Story of a Standard: The Development of COA's Adult Foster Care Standards

The Story of a Standard: The Development of COA's Adult Foster Care Standards

I love solving puzzles! My two favorite distractions during my daily commute are the New York Times crossword and Sudoku puzzles. I rack my brain trying to remember bits of trivia (what are the periods after Mardi Gras?) and thank my years of Spanish for providing me the answer to 67 across (“You are”, south of the border?). Although not a job requirement, my passion for puzzling comes in handy at the Council on Accreditation (COA). Developing new standards can be like unraveling a puzzle in many ways. One step at a time, we must figure out how to untangle and interpret the research, decipher regulations, connect best practice to the work on the ground, and assemble and then reassemble all the pieces to fit a diversity of programs.

In this article, we will be examining some of the puzzle pieces of the Adult Foster Care (AFC) standards. A crucial player in the standard development process are experts in the field. As we walk-through elements of the AFC standards, make note of your thoughts and recommendations. We’ll give you guidance on how to share your voice with us and participate in the development process at the conclusion of this post.

Let’s first define Adult Foster Care.

The legal definition of Adult Foster Care is a system in which adults who are not able to care for themselves are placed in private care homes. The Massachusetts AFC regulations get a little bit more specific, stating that a multidisciplinary team and nursing supervisor assist in the care.

So who are the adults who may benefit from these higher level supports? How do we draw a line between being unable to care for themselves and a need for serious, round the clock care that may necessitate a higher level of supervision (e.g., a nursing facility)? Drawing the line of ability comes down to how capable these individuals are to live independently. The state of Oregon defines this as their ability to complete everyday tasks of life, also referred to as Activities of Daily Living (ADL), and they have outlined some criteria that may potentiate an individual’s appropriateness for AFC:

  • Difficulty preparing meals or maintaining adequate nutrition
  • Forgetting to take medications or taking the wrong amount
  • Inability to manage daily personal needs such as bathing, dressing, shopping, cooking, laundry, or transportation
  • Bruising, scratches, or other injuries from falls
  • Ongoing illness or a need for rehabilitation
  • Difficulty coping with feelings of depression, anxiety, or fear
  • Difficulty remembering people, places, or other things that were once familiar
  • Family and friends are no longer able to provide adequate care and support

Adult Foster Care may be provided in the form of board and care facilities, large group homes, small group homes, as well as individual private homes in a residential-zoned neighborhood, sometimes in conjunction with case management or home-based primary care. Two examples of Adult Foster Care program models are Community Residential Care (a VA model) and Medical Foster Homes.

This gives us a general picture of the kind of service we are looking at, but what are the advantages? How do we better support service delivery?

What are advantages of Adult Foster Care?

One of the main advantages of Adult Foster Care is that it not only allows for adult service recipients to maintain or regain their independence, but it can also be an economical option that allows for more comprehensive care of the individual.

AFC homes are generally more cost-effective than their nursing facility alternatives, owing to the fact that the home and facilities are already owned and maintained by the caregivers. They also provide lower level services, addressing the need to pay for round the clock aides that might be employed by a nursing facility. Some estimates of the cost difference project a savings of as much as half of what nursing facility would cost ($40-per-day vs. $92-per-day).

The overall care tends to be more comprehensive as well. The structure of AFC allows for more formalized individualized care. Instead of the service recipient relying upon the services the facility is able to provide, the service plan and case worker ensure that the service recipient has access to all possible services needed. Also, due to the limited beds within one private home, the ratio of helping hands to service recipients is greater. The service recipient is also an integrated member of the community so there are more eyes on their well-being than just the caregiver. Individuals accessing AFC have significant overlap with individuals who are vulnerable to abuse and neglect, so being part of the community ensures there are more opportunities for identifying signs of maltreatment.

What are the barriers?

Adult Foster Care appears to have many benefits, but you may be wondering why it isn’t so common. Well, it’s not a perfect system. There are still kinks to be worked out.

One of the biggest issues (and one that plagues many parts of the human services system) is allocation of Medicaid dollars. Due to a difficult funding environment, Medicaid waiver programs like the Home and Community Based Services are developing more restrictive qualification criteria. This makes for longer waitlists and creates constraints on the number of people able to access the service.

Finding appropriate primary caregivers whose abilities match the needs of the populations can also be a barrier to the success of these programs. Some states limit what caregivers can do, such as administering medication, which then necessitates the use of nursing staff. This in turn drives up both the cost and demand for staff, limiting AFC’s accessibility.

Where do we go from here?

To deal with the issues listed above, we need to push for more Medicaid funding to HCBS waiver programs. This is both economical and helps to diversify services provided. The Department of Veteran Affairs has cited diversified resources as a factor that drives increased access, improved quality, and reduced total costs of health care.

Also, more emphasis must be placed on both recruitment and admission assessments. AFC programs are only as strong as their ability to properly place service recipients in homes. By strengthening these two areas, we are more likely to successfully place individuals in qualified homes with appropriate caregivers, matching the needs of the service recipients with the abilities of caregivers. In COA’s accreditation standards for Adult Foster Care we will address best practices in both assessment and recruitment. Some other core service components that will be addressed include service planning and coordination, service monitoring and reassessment, and caregiver training and support. Areas of significant vulnerability for the service population, such as abuse and suicidality, will be highlighted throughout.

Join the conversation.

We are in the early steps of the standards development process. The points we discussed above will continue to evolve. Please join the conversation! Is there anything else you think could help make these programs more successful? Do you have any ideas as how to best utilize these programs? If you are interested in participating then do one or both of the following:  

  1. comment below!
  2. email me at ileventhal@coanet.org to get involved with our upcoming standards advisory panel discussion.
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